INDEPENDENT PROVIDER
REQUIRED DOCUMENTS LIST

Below is a list of documents that will be reviewed during the compliance review, please have these items available at the beginning of the onsite review. Additional documents may be requested during the onsite review. Depending on the type of waiver and services provided some items will not apply to the review. Please contact the reviewer with any questions prior to the onsite review.

ISP for Individuals in Sample / Completed
  1. Current and previous service plan, addendums and revisions
(Please note that the service plan should include information on restrictive measures or supports for behavioral concerns)
  1. Assessments used to develop the service plan

  1. Plan of Care signed by physician forWaiver Nursing

MEDICATION ADMINISTRATION for Individuals in Sample if applicable
  1. Current Self-Medication Assessment

  1. Medication Administration Records (MAR) for the last 3 months

  1. Physician’s orders

DELEGATED NURSING(if applicable)
  1. Evidence of nurse supervision of delegation
  2. Log Notes
  3. Nursing Notes
  4. Any documentation used by delegating nurse to evidence supervision
  5. Any special conditions identified by the nurse
  6. On-going nursing assessments
  7. Statement of delegation
  8. Annual staff skills checklist
  9. Name and credentials of the Delegating Nurse

WAIVER NURSING SERVICES (RN/LPN only)
  1. Evidence of:
  2. Clinical Notes and/or Nursing Notes
  3. Documentation of consultations with directing RN (LPN only)
  4. Evidence of 120 day face-to-face visit with the individual and the directing RN
  5. Evidence of 60 day face-to-face visit with the RN
  6. Name and credentials of the nurse providingdirection to the LPN

BEHAVIOR SUPPORT for Individuals in Sample(if applicable)
  1. Evidence that plans with restrictive measures are reviewed every 90 days
*Please provide last 3 status reports
  1. Evidence the provider was trained on restrictive measures

DOCUMENTATION for Individuals in Sample
  1. Waiver service delivery documentation for the last 3 months, including money management (ledgers, receipts, bills), behavior support, and healthcare, if required by the service plan.
For employment services this includes the name of the individual’s employer, number of hours worked and hourly wage.
  1. For providers of employment services evidence that a written progress report was submitted to the individual’s team.

  1. For providers of employment services evidence that employment outcome data was submitted to the web-based data collection system maintained by DODD.

  1. For providers of employment services evidence that documentation includes the name of the individual’s employer, # of hours worked and hourly wage.

Training/Certification for PROVIDER
  1. Evidence of annual MUI/UI training and training on the health and welfare alerts

  1. Evidence of annual individual rights training

  1. Evidence of additional annual training- as required by the waiver service the provider is delivering

  1. Evidence of training on current ISP/BSP

  1. Current First Aid certification- please note that online only certification will not be accepted. Online training must include evidence of hands on skills component.

  1. Current CPR certification- please note that online only certification will not be accepted. Online training must include evidence of hands on skills component.

  1. Evidence of Medication Administration Certification (if applicable)

  1. Evidence of any professional license/certification(s)

  1. Evidence of successful completion of DODD Support Broker Training- SELF Support Broker ONLY

  1. Money Management Waiver service: Evidence of annual training on topics that enhance competency relevant to providing money management

SELF SUPPORT BROKER
  1. Evidence of successful completion of DODD Support Broker Training

MUI/UI

26.MUI and UI reports for the last 9 – 12 months, including follow up on incidents

27.UI Log(s) and evidence of monthly UI reviews for the last 3 months – additional reports may be requested onsite

DRIVERS / TRANSPORTATION

  1. Evidence of valid driver’s license (if responsible for transporting individuals)

  1. Evidence of current insurance policy for vehicles that are used to transport individuals

30.Annual vehicle inspections – (Non-Medical transportation only)

31.Daily Pre-Trip Inspection Sheets - (Non-Medical transportation only)

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DODD Form 014F–Effective 10/1/17